The Ontario Superior Court of Justice recently determined that, under both Ontario’s health care consent legislation and common law, physicians do not require consent to withhold cardiopulmonary resuscitation (CPR) that they believe to be medically inappropriate.
Physicians in Ontario need to distinguish carefully between a scenario where CPR would be outside the standard of care and should not be offered and a scenario where CPR is within the standard of care but the physician does not feel it is in the patient’s best interests; each scenario demands a different response.
Physicians still have a professional responsibility to communicate (or make reasonable efforts to communicate) honestly and compassionately about the limitations of CPR and the alternatives to aggressive care.
Abstract Most discussions of conscientious objection in healthcare assume that the objection is universal: a doctor objects to all abortions. I want to investigate selective objections, where a doctor objects to one abortion but not to another, depending on the circumstances. I consider not only objections to abortion, but also objections to the withdrawal of life-saving treatment at the request of a competent patient, which is almost always selective. I explore how the objector might articulate the selective objection, and what impact it might have on the patient, within the conceptual space of relevant statutes and professional guidelines.
Abstract In Confucian societies, people tend to avoid the discussion on death matters, let alone making advance directives to reject life-sustaining treatments at the end of life. Taiwan might be a pioneer in legislating the right-to-die with dignity among Confucian countries. As early as 2000, the Hospice Palliative Care Act was declared in Taiwan, which give terminally-ill patients the options to forgo life-sustaining treatments. Furthermore, in 2016, Taiwan passed the Patient Right to Autonomy Act to enhance patients’ choice at the end of life and expanded the coverage to certain types of non-terminally ill patients. On the other hand, end-of-life issues in Japan are regulated mainly through courts’ judgments and medical societies’ guidelines. Korea passed a law to legalize passive euthanasia, which became effective in 2018, but only contains limits to terminally-ill patients.
This paper is divided into three sections. First, this paper analyzes the sociocultural emphasis on family unity in East Asia and attitudes toward death in East Asian cultures, and then the methods adopted in Japan and South Korea of solving related disputes through the judiciary or legislation are explained. Second, the paper describes the legislative background of the aforementioned two laws in Taiwan, including futile medical care, the denial of citizen autonomy with respect to serious injury and death by criminal law theory, the unwillingness of the judiciary to intervene, and disputes encountered at medical sites. Subsequently, we explain the primary content of these two laws, including patients’ rights to self-determination, the judgment procedures of medical institutions, and the operation of advance directives. Finally, this paper analyzes inadequacies in the Patient Right to Autonomy Act, including a lack of penalties, insufficiencies in medical institutions’ scope of duty of disclosure, and the lack of a settlement mechanism for individuals who have not yet established advance directives.
Abstract Some people will confront Alzheimer’s with a measure of resignation, a determination to struggle against the progressive debilitation and to extract whatever comforts and benefits they can from their remaining existence. They are entitled to pursue that resolute path. For other people, like myself, protracted maintenance during progressive cognitive dysfunction and helplessness is an intolerably degrading prospect. The critical question for those of us seeking to avoid protracted dementia is how best to accomplish that objective. One strategy is to engineer one’s own death while still mentally competent to do so (even in the stage of mild dementia). If I were to use a preemptive strategy in the face of a dementia diagnosis, I would probably choose to stop eating and drinking, a process known as voluntarily stopping eating and drinking. An alternative tactic for avoiding prolonged dementia would be to allow oneself to decline into moderate dementia—thus losing capacity to perform self-deliverance or even to make serious medical decisions—but before getting to that point to provide advance instructions rejecting prospective life-sustaining medical interventions. These advance instructions would authorize palliative but not curative measures. My current personal instructions define the point of intolerable cognitive decline triggering medical nonintervention as “mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook.” These instructions dictate allowing my demise at a point of moderate dementia when I may not be perceptibly suffering, when I may still be getting some rudimentary satisfaction from my debilitated life, and when I no longer recall the preoccupation with personally intolerable indignity that motivated my instructions. Can I expect that my advance instructions will be implemented in those circumstances? Is it lawful, and is it moral for a surrogate decision-maker and associated caregivers to allow an uncomprehending, ostensibly content but demented individual to die? My analysis herein contends that it is not only lawful and moral but also legally required to implement clear, considered advance instructions even at a stage of moderate dementia.
Abstract In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision‐makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient‐centered healthcare. When there is ambiguity as to the patient’s advanced wishes, the presumption has been that decisions should weigh in favor of maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient’s advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient’s wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient.
Abstract When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infant’s future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View, treatment may be withdrawn from infants if their future well-being is below a threshold that is close to, but above the zero-point of well-being. I present four arguments in favor of the Threshold View, and identify and respond to several counterarguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant’s life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust, and potentially more practical than the standard view.
Abstract The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient’s autonomy and doctor’s duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive.
Extract In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses’ participation and the representation of caring issues. Therefore, questions about the design of Hospital Ethics Committees and how their practices really look like, will be raised. The central question is, how the traditional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.
. . . .My observations and interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of- life questions and regulations of tube-feeding. The “cases” for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by translating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates in the political arena. Technical procedures given by management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think – what is at stake for patients – in terms of caring relations rather than thinking in terms of rules, regulations and control.
Extract This symposium issue explores several continuing controversies at the intersection of Law, Ethics, Healthcare, Politics, Health Policy and Religion: abortion, contraception, the status of embryos, stem cell research, IVF, personal and professional autonomy, end- of-life decisions, and religiously based health care systems. The multiple values associated with each of these topics strain and threaten to usurp the effectiveness of our legal system to regulate them.
Anita Catlin, Deborah Volat, Mary Ann Hadley, Ranginah Bassir, Christine Armigo, Elnora Valle, Wendy Gong, Kelly Anderson
Neonatal Network
Abstract This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, fi.itility, and the concept of conscientious objection from the perspective of the nurse’s potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.
